What accounts for the dramatic decline in the number of doctors opting to be primary-care physicians? Simple economics, mostly. "They're not dumb," says Candice Chen,...

What accounts for the dramatic decline in the number of doctors opting to be primary-care physicians? Simple economics, mostly. "They're not dumb," says Candice Chen, a professor of pediatrics and health policy at George Washington University. "They do notice that if you're a specialist, you'll make four to five times more than a primary-care doctor."

One of the problems is distorted Medicare reimbursement rates that pay more to specialists. In addition, many of the things that primary-care doctors do, such as giving advice and responding to patient e-mails, are not usually compensated at all. Medical schools and residency programs also have tilted toward specialists in recent years.

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The result is that today's primary-care physicians tend to be aging baby boomers who feel overworked and underpaid--and are talking about retirement. With universal health care on the agenda in Washington, there are serious questions as to whether the existing primary-care network can handle expanded access to health insurance. After Massachusetts implemented near- universal health insurance a few years ago, wait times for primary-care doctors increased. Today, more than one-third of primary-care doctors in the state report that they aren't accepting new patients.

This is significant, since research links an adequate supply of primary-care doctors to better health outcomes and lower health costs. Efforts to coordinate care, such as the medical-home model, depend on primary-care providers.

Even if reimbursement rates change and medical education finds a way to encourage young doctors to turn to primary care, these solutions will take years to have a significant effect on the supply of primary-care doctors in the workforce. The answer may lie in developing nurse practitioners and physician assistants who can take up some of the slack--working in coordination with primary-care practices. And, once again, it may be up to the states to find a way to make this solution work.

Wisconsin just got approval to implement the new rule, and it will take effect in two other states in January. Meanwhile, more than 8,000 people have lost health insurance in Arkansas -- many who may comply with the rule but not know about it.